ARTIGO ORIGINAL / ORIGINAL ARTICLE

Anlise funcional dos estabilizadores patelares

Functional analysis of the patellar stabilizers
DBORA BEVILAQUA GROSSI1, VANESSA MONTEIRO PEDRO 2, FAUSTO BRZIN3

RESUMO
O msculo vasto medial obliquo (VMO) desempenha importante papel na estabilizao medial da patela. No entanto, o padro de recrutamento dos componentes laterais, o msculo vasto lateral longo (VLL) e vasto lateral obliquo (VLO) no est estabelecido. O objetivo deste trabalho foi analisar a atividade eletromiogrfica dos msculos VMO, VLL e VLO de 21 indivduos saudveis (X=23,3 e DP=2,9), sendo 10 mulheres e 11 homens, sem histria clnica de dor ou leso osteomioarticular. Para tanto foi utilizado um eletromigrafo NICOLET VIKING II de 8 canais (NICOLET Biomedical Instruments) e eletrodos bipolares de superfcie para registrar a atividade eltrica dos msculos VMO, VLL e VLO durante a realizao de exerccios isomtricos de extenso do joelho a 15 e 90 de flexo. Os dados eletromiogrficos foram normalizados pela contrao isomtrica voluntria mxima de extenso do joelho a 50 de flexo e revelaram que os msculos VLL e VLO apresentam diferena significativa no padro de recrutamento podendo ser considerados fisiologicamente distintos. O msculo VMO desempenhou juntamente com o VLO um papel recproco e sincrnico na estabilizao patelar e apresentou maior ativao em relao ao msculo VLL nos exerccios isomtricos de extenso do joelho a 90. Descritores: Joelho; Msculo; Eletromiografia.

SUMMARY
The vastus medialis obliquus muscle (VMO) performs an important role in the medial patellar stability . However , the recruitment of the lateral components, the vastus lateralis longus (VLL) and vastus laterallis oblique (VLO) is not established. The main purpose of this work was to investigate the electromyographic (EMG) activity of the VMO, VLL and VLO muscles of twenty one health volunteers (X= 23,3 DP 2,9), 10 female and eleven males, without clinical pain symptoms or osteomioarticular injuries EMG NICOLET VIKING II was used with eight channels (NICOLET Biomedical Instruments, and bipolar electrodes surface in order to record the electrical activity of VMO, VLL and VLO muscles during a isometric knee extension at 15 and 90. The EMG data were normalized by maximum voluntary contraction (MIVC) of the knee flexion at 50 has shown that the VLL and VLO muscles demonstrated significant difference in recruitment pattern and they can be considered physiologically distinct. The VMO and VLO muscles performed synchronic and reciprocal role in the patellar stability and the VMO muscle performed higher activity compared with the VLL muscle in isometric knee extension at 90.

Key words:Knee, Muscle, Electromyography.

INTRODUO
As desordens femoropatelares so provavelmente a causa mais comum de patologia no joelho encontradas em clnicas de ortopedia e medicina esportiva(6). Os pacientes com sintomas de dor femoropatelar permanece como um dos maiores desafios clnicos em medicina de reabilitao a despeito dos recentes avanos no entendimento e tratamento de diversas condies do joelho(25).

INTRODUCTION
The patellofemoral disorders are the most likely pathology in the knee seen in orthopedics and sports medicine clinics(6). The patients with patellofemoral pain symptoms are one of the biggest clinical challenges in rehabilitation medicine considering the most recent advances in the diagnoses and treatment of several knees condition(25).

Trabalho realizado no Laboratrio de Eletromiografia do Departamento de Morfologia da Faculdade de Odontologia de Piracicaba (FOP)UNICAMP 1.Profa. Doutora do Departamento de Biomecnica, Medicina e Reabilitao do Aparelho Locomotor-FMRP - USP 2.Profa. Adjunto-IV do Departamento de Fisioterapia UFSCar 3. Prof. Titular do Departamento de Morfologia (FOP UNICAMP) Endereo para Correspondncia Av. Bandeirantes, 3900 - Cep: 14049-900 Ribeiro Preto SP - Tel: (16) 6022418 Fax: (16) 6330336 - e-mail: deborabg@fmrp.usp.br Trabalho recebido em 17/09/03. Aprovado em 09/04/04.
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Work performed at the Electromyography Laboratory of Morphology Department of Dentistry College of Piracicaba (FOP) UNICAMP 1 - PhD Professor of the Biomechanical Department, Medicine and Rehabilitation of the Locomotors- FMRP USP 2 - Associate Professor IV Professor of the Physiotherapy Department UFSCar 3 - Chairman of the morphology Department (FOP - UNICAMP) Adress: Av. Bandeirantes, 3900 - Cep: 14049-900 Ribeiro Preto SP Phone (16) 6022 418 Fax: (16) 6330336 -e-mail: deborabg@fmrp.usp.br

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Uma das caractersticas mais comuns nos pacientes com dor femoropatelar o desalinhamento do mecanismo extensor, que resulta em atrofia e diminuio da fora do msculo vasto medial e desequilbrio entre os componentes laterais e mediais do quadrceps(4,22). O vasto medial dividido em duas pores, uma proximal denominada de vasto medial longo (VML) e outra distal, o vasto medial obliquo (VMO). Essas pores apresentam diferenas anatmicas(2,11,12,23), funcionais(2,13,17), histoqumicas(21) e tambm no padro de inervao(12,18,20). Mais recentemente, o msculo vasto lateral passou a ser estudado anatomicamente e, como o VMO, tambm foi dividido em duas pores: uma proximal, denominada de vasto lateral longo (VLL) e outra distal, o vasto lateral oblquo (VLO)(1,11,18,23)(Figura1). Alm disso, o VLO passou a ser estudado tambm pela importncia clnica na tcnica cirrgica do release lateral, cuja liberao diminui o tempo de recuperao ps operatria, quando comparado com a transeco de todo vasto lateral (7). A atividade eletromiogrfica dos msculos VMO e VLL tem sido bastante estudada em cadeia cintica aberta e em diferentes ngulos de flexo do joelho(3,4,6,15). No entanto, apesar de Weinstabl et al.(23) sugerirem diferenas funcionais entre os msculos VLL e VLO, o padro de atividade eltrica destes msculos ainda no foi estudado. Morrish e Woledge(16) compararam o padro de atividade eltrica dos msculos VMO e VLO em indivduos normais em exerccios de cadeia cintica aberta a 20 de flexo do joelho e no encontraram diferena significativa entre os dois msculos neste ngulo. Considerando a importncia de melhor entendimento dos fatores envolvidos na disfuno femoropatelar e do pouco conhecimento do papel dos componentes mediais e laterais do quadrceps na estabilizao da patela, o objetivo deste estudo foi analisar a atividade eltrica dos msculos VMO, VLL e VLO em exerccios de extenso do joelho em cadeia cintica aberta nos ngulos de 15 e 90 de flexo.

One of the most common characteristics in patients with patellofemoral pain is the extensor mechanism disorder, which results in atrophy and strength reduction of vastus medialis muscle and unbalancing of the lateralis and medialis quadriceps components(4, 22). The vastus mediallis is divided into two parts, one proximal called vastus mediallis longus (VML) and another distal one, the vastus mediallis obliquus (VMO). These parts show anatomical(2,11,12,23), functional(2,13,17), histochemistry(21) differences and in the pattern of innervations as well(12,18,20) (Figure 1). In addition, the VLO started also be studied because of clinical surgical importance technique of release lateral, which the releasing decreases the post operation recovery, as compared with the transaction of all vastus lateralis(7). The muscles VMO and VLL electromyographic activity have been studied in each opening kinetic chain and in different angles of knee flexion(3,4,6,15). However, despite Weinstabl et al(23) suggest functional differences between the VLL and VLO muscles, the electrical pattern activity has not been studied yet. Morrish & Woledge(16) compared the electrical pattern activity of the VMO and VLO muscles in normal clinical patients doing exercise of kinetic chain at 20 knee flexion and the authors not found any significant difference between these two muscles with this angle. Considering the importance of understanding the involved factors in patellofemoral this disorder and the poor knowledge about the role of the medially and laterallis components of the quadriceps in the patella stability, the main purpose of this study was figure out the electrical VMO, VLL, and VLO muscles activities with the flexion knee extension exercise in a kinetic at 15 and 90 of the knee flexion.

MATERIAL AN METHODS MATERIAL E MTODOS

SUJEITOS Os msculos vasto medial oblquo (VMO), vasto lateral oblquo (VLO) e vasto lateral longo (VLL) foram analisados eletromiograficamente em 21 voluntrios, sendo 10 do sexo feminino e 11 do sexo masculino, com idade de 19 a 28 anos (X=23,32,9) sem histria clnica de cirurgias, dor ou leso osteomioarticular nos membros inferiores. O estudo foi conduzido de acordo com a resoluo 196/96 do Conselho Nacional de Sade. EQUIPAMENTOS Os registros eletromiogrficos foram captados por eletrodos bipolares de superfcie com dimetro de 11mm e superfcie de deteco de 2mm conectados ao eletromigrafo VIKING II de oito canais (NICOLET BIOMEDICAL INSTRUMENTS). A calibrao do equipamento variou de 200 a 500mV diviso e a velocidade de deslocamento do feixe foi de 200ms/diviso. Os filtros foram fixados numa amplitude de 10Hz para baixa freqncia e de 10 KHz para alta freqncia . PROCEDIMENTOS Os eletrodos foram fixados sobre a pele, previaThe vastus medialis obliquus (VMO),vastus lateralis obliquus (VLO) and vastus lateralis longus (VLL) were evaluated by the use of electromyography in 21 volunteers, ten female and 11 male, aged from 19 to 28 (X=23,32.9) had no previous surgery, pain or osteomyarticular injury in the lower limbs. The study was led with the 196/96 resolution of the Health National Council.

Figura 1 - Vista lateral da coxa direita evidenciando o msculo vasto lateral oblquo (VLO) com sua origem no septo intermuscular lateral (SIL) e sua insero na borda superior e lateral da patela (P), msculo vasto lateral longo (VLL). Figure 1 - Lateral view of the right thigh evincing the oblique lateral vast muscle (VLO) with its origin in the lateral intermuscular septum (SIL) and its insertion in the upper and lateral patellar edge, long lateral vast muscle (VLL).

EQUIPAMENT
Electromyography records were obtained by bipolar surface electrodes with 11mm diameter and detection surface of 2mm connected to the electromyography Viking II of eight channels (Nicolet Biomedical Instruments). The calibration of the equipment ranged from 200 to 500V, the division and speed of the beam displacement was of 200ms/division. The filters were fixed with amplitude of 10 Hz low frequency and 10KHz high frequency.

PROCEDURES
The electrodes were fixed on the skin, previously trichotomized and hygienized with alcohol at 70%, in order to reduce the impedance and eliminate any unexpected interferences. Before the elec-

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mente tricotomizada e realizada a limpeza com lcool 70%, a fim de reduzir a impedncia e eliminar eventuais interferncias. Antes da fixao os eletrodos foram untados com gel eletrocondutor e fixados pele no sentido longitudinal das fibras musculares por meio de fita adesiva micropore (3M do Brasil). A distncia entre o centro de cada eletrodo foi de 2 centmetros. Um eletrodo terra tambm untado com gel eletrocondutor foi fixado tuberosidade anterior da tbia.

trodes fixation they had been greased with gel and fixed to the skin at longitudinal direction from the muscular fibers with microspores scotch tape (3M of Brazil). The distance between the centers of each electrode was of 2cm. An earthed connected electrode was greased with gel and fixed to the anterior tibia tuberosity. To install the electrodes in different parts of the quadriceps muscle, a line was traced from the antero superior iliac spine (ASIS) to the center of patella, as a pattern of the inclination angle of the measurement of each portion(1). The pair of electrodes on the VMO was placed on the belly of the muscle at an inclination of 55(12). The VLL electrodes were placed at 15cm from the superior and lateral edge of patella at an inclination of 13.6. The VLO shows its superficial part located around 2,2 cm of the lateralis epicondyle, with a superficial length of about 8.9cm. To insert the electrodes on this muscle, the femoral lateralis epicondyle was located and the beginning and center of the VLO belly muscle at an inclination of 50,4(1) (Figure 2).

Para a colocao dos eletrodos nas diferentes pores do msculo quadrceps, foi traado uma linha da espinha ilaca ntero-superior (EIAS) ao centro da patela (C), para servir de referncia na medida dos ngulos de inclinao de cada poro(1). O par de eletrodos sobre o m. VMO foi posicionado sobre o ventre muscular numa inclinao de 55 0(12). Para o m. VLL os eletrodos foram posicionados a 15 cm da borda superolateral da patela numa inclinao de 13.60. O VLO apresenta sua poro superficial localizada cerca de 2,2 cm do epicndilo lateral, com um comprimento superficial de 8,95 cm em mdia, para a colocao dos eletrodos sobre este msculo loca- Figura 2 - Posicionamento dos lizou-se o epicndilo lateral do fmur e o incio e o eletrodos nos msculos vasto medial oblquo (VMO), vasto meio do ventre muscular do VLO com uma inclinalateral longo (VLL) e vasto lateral o de 50,4 0(1) (Figura 2). obliquo (VLO) de acordo com a inclinao de cada poro em relao linha da espinha ilaca POSITIONS AND EXERCISES ntero-superior (EIAS) ao centro POSIES E EXERCCIOS da patela (C). The knee isometric extension exercises at15, Os exerccios de extenso isomtrica do joelho nos Figure 2 - The electrodes place 50and 90 angles of knee flexion were performed on an extensor flexor table, which allowed the limb ngulos de 15, 50 e 90 de flexo do joelho, foram in the vastus medialulis realizados em uma mesa flexo-extensora(14), que per- obliquuus (VMO), vastus lateralis mechanical fixation of different knee flexion anmitia a fixao mecnica do membro nos diferentes longus (VLO) according to the gle, leading to a maximum voluntary isometric contraction (MVIC) in each exercise performance. ngulos de flexo do joelho, proporcionando uma coninclination of each part in trao isomtrica voluntria mxima (CIVM) em cada relation of the anterous-superior The volunteer remained sat with the trunk and hips flexioned at 90 and stabilized with two belts: an ngulo. O voluntrio permaneceu sentado com o troniliac spine line (ASIL) to the auxiliary and a pelvic one. co e o quadril fletidos a 900 e estabilizado com dois center of the patellar. cintos: um axilar e outro plvico. The exercise performance order was random and before the beginning of each test, the familiarization with the A ordem de execuo dos exerccios foi aleatria e antes do incio exercises was done. The time performance of each contraction de cada exame foi realizado uma familiarizao com os exerccios. O was of 5 seconds with a break of 60 seconds between each tempo de execuo de cada contrao foi de 5 segundos com interrepetition and ten minutes between the set of exercises. The valo de 60 segundos entre cada repetio e de 10 minutos entre cada electromyographic data were normalized considering the MVIC srie de exerccios. Os dados eletromiogrficos foram normalizados of the knee extension at 50 of the knee flexion according to pela CIVM de extenso do joelho a 50 de flexo do joelho de acordo Hanten & Schulthies(8). com Hanten e Schulthies(8). Para comparao entre os msculos nos diferentes ngulos foi empregado o teste de anlise de varincia no paramtrico (ANOVA). Comparing the muscles at the different angles studied, analyses of variance test was used.

RESULTADOS
A comparao entre os msculos VMO, VLL e VLO revelou que no exerccio de extenso isomtrica a 15 de flexo do joelho no h diferena na ativao destes msculos (p=0.06). Por outro lado, ao realizar os mesmos exerccios com o joelho fletido no ngulo de 90 os msculos VMO e VLO apresentaram o mesmo comportamento e foram significativamente mais ativos do que o msculo VLL (p=0.02) (Tabela 1). Na comparao entre ngulos, apenas o msculo VLL apresentou padro de ativao distinto, isto , apresentou maior atividade nos exerccios de extenso a 15 do que a 90 (p=0.04). Por outro lado, a variao dos ngulos no interferiu na atividade dos msculos VMO e VLO (Tabela 1) .
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RESULTS
The comparison among VMO, VLL and VLO muscles showed that isometric extension exercise at 15 knee flexion there is difference in activation pattern of these muscles (p=0.06). On the other hand , the performance of the same exercises at 90 of knee flexion, the VMO and VLO muscles showed the same behaviour and were significantly more active than the VLL muscle (p=0,02) (Table 1). The comparison among the angles, only the VLL muscle showed a distinct activation pattern, that is, higher activity at the extension exercise at 15 than at 90 (p=0,04). On the other hand the angle variation did not make any difference in the VMO and VLO muscles (Table 1)
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VMO X 15 90 Valor de p para comparao entre os ngulos estudados P value considered for comparisons among studied angles . 148,6 154,4 0.82 DP 84,9 49, 3 0.004 X

VLL DP X

VLO DP 46,6 58,7 Valor de p para comparao entre msculos Value of p comparison among muscles 0.06 0.02

161,5 56,1 136,8 131,3 43,9 158,7 0.27

Tabela 1 - Mdia (X) e Desvio Padro (DP) dos valores de RMS normalizados pela CIVM a 50 de flexo do joelho dos msculos vasto medial oblquo (VMO), vasto lateral longo (VLL) e vasto lateral oblquo (VLO) nos exerccios isomtrico de extenso do joelho a 15 e 90 de flexo (n=21). Valores significativos para p0.05. Table 1 Median (X) and standard deviation (DP) of the RMS values normalized by CIVM at 50 of knee flexion of the vastus medialis obliquus muscle (VMO), vastus lateralis longus (VLL) and vastus lateralis obliquuus (VLO) during isometric exercises the knee extension at 15and 90of flexion (n=21) significant difference at p0.05.

DISCUSSO
Um dos propsitos deste estudo foi verificar se os msculos VLL e VLO apresentavam diferenas funcionais, e os resultados revelaram que estes msculos possuem um padro diferente de recrutamento, isto , alm das diferenas anatmicas(1) apresentam padro de ativao distintos. Nos exerccios de extenso isomtrica de joelho a 15 de flexo, estes msculos no apresentaram entre si diferena significativa, e diferentemente do VLO que manteve o mesmo padro de recrutamento independente do ngulo de flexo do joelho, o VLL significativamente mais ativo na extenso do joelho a 15 do que a 90. Embora a diferena no tenha sido significante, Boucher et al.(3), tambm encontraram maior atividade do VLL a 15 do que a 90. Da mesma forma, Escamilla et al.(6) tambm relataram maior atividade do msculo VLL nos ltimos graus de extenso. Cerny(4), atribuiu esta maior atividade do VLL a 15 desvantagem mecnica em decorrncia do aumento da gravidade e do brao de alavanca do msculo quadrceps, alm da diminuio do comprimento muscular. Para Boucher et al.(3), o msculo VLL quando em atividade na CIVM 15 de flexo, est mais envolvido com a extenso do joelho do que a estabilizao da patela. Isto se justifica tambm pelo alinhamento das fibras do VLL, cuja tendncia tracionar a patela superiormente promovendo a extenso, diferentemente do VLO, que com suas fibras em espiral e inclinadas em relao difise femoral(1) se responsabiliza pelo alinhamento da patela juntamente com o VMO. Alm disso, o msculo VLL apresenta maior massa muscular(24) com um componente de tracionamento maior do que o VLO, estando, portanto, mais propenso s alteraes no seu comprimento. Por outro lado, na CIVM 15, ambos esto numa posio de encurtamento onde apesar das diferenas anatmicas, a constituio e a disposio das fibras parecem no promover grandes alteraes na relao comprimento tenso. Os resultados deste trabalho sugerem que ao realizarmos os exerccios nos ltimos graus de extenso, alm de no ativarmos preferencialmente o VMO, favorecemos a ao do VLL, podendo contribuir para o desequilbrio patelar. Em relao atividade eltrica do msculo VLO, o nico trabalho encontrado na literatura pesquisada at a presente data, que faz referncia direta ao estudo eletromiogrfico do VLO o de Morrish e Wo 102

DISCUSSION
One of the purposes of this study was to verify if the VLL and VLO showed differences in their function, and the results revealed different recruiting pattern in these muscles, besides the anatomical differences(1) they also showed distinct activation pattern. During the isometric extension exercises of knee at 15flexion, these muscles did not show any remarkable difference among them, differently from VLO, which remained with the same recruitment pattern independent of the knee flexion angle, the VLL is significantly more active during the knee flexion at 15 than at 90. Although the difference was not so significant, Boucher et al.(3), also observed more VLL activity at 15 than 90. Either, Escamilla et al.(6) also reported more activity of the VLL muscle at last knee extension degree. Cerny(4), associated this higher VLL activity at 15 as a mechanical disadvantage due to the increase of the gravity and the lever of the quadriceps muscle, besides the decrease of the muscle length. According to Bouncher et al.(3), the VLL muscle while working in MICV at 15 flexion, is more involved in the knee extension than the patella stability. This also shows the VLL fibers alignment that tends to tractionate patella promoting the extension, differently from the VLO which spirally and inclination fibers in relation to femoral dyaphisis promotes(1) the patella alignment associated to the VMO. In addition, the VLL muscle shows a greater muscular body(24) with a higher traction component than the VLO, therefore, more available to alterations in its length. On the other hand at (MIVC) 15, both are in the shortening position spite of the anatomical differences, the fibers structure and disposition seem not promoting important alterations in relation of the length tension. The comes out of this work suggest when doing the exercise at the last extension degrees, besides not activate preferably the VMO, the action of the VLL is preferred, contributing to the patellar balancing. About the VLO muscle electrical activity , the only work referring to the VLO electromyographical study, is the one by Morrish & Woledge(16), who also studied the VMO at 20 degree knee flexion in an opening kinetic chain and no important differences

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ledge(16), que tambm analisaram o msculo VMO no ngulo de 20 de flexo do joelho em cadeia cintica aberta e, no encontraram diferenas significativas na atividade destes msculos que foi praticamente sincrnica, sugerindo uma atividade recproca no controle patelar. De acordo com Javadpour et al.(11) o equilbrio entre a trao do VMO e VLO primordial j que o fator muscular que determina a posio da patela, uma vez que o exerccio em cadeia cintica aberta de extenso da perna isola a contrao do quadrceps. Os dados deste estudo revelaram que os msculos VMO e VLO apresentam o mesmo comportamento sugerindo um papel estabilizador sincrnico e com uma funo antagonista na estabilizao patelar em indivduos normais. Por outro lado o vetor de fora exercido pelo msculo VLO, intimamente associado ao tracto liotibial e retinculo lateral(1) pode ser capaz de alterar o equilbrio normal da patela, gerando tenso excessiva nessas estruturas podendo desencadear um quadro de dor e mau alinhamento patelar. O conceito de que o msculo VMO mais ativo durante os ltimos graus de extenso amplamente aceito(6,13,17), o que subsidiou o uso destes exerccios no tratamento conservador. Da mesma forma, o conceito de que a fora de reao femoropatelar aumenta com a flexo do joelho e diminui na medida que alcanava-se a extenso final proposto por Hungerford e Barry(10), contribuiu para que o protocolo de exerccios para estes pacientes fosse baseado em exerccios realizados nos ltimos graus de extenso. Os dados deste trabalho revelaram que o msculo VMO no mais ativo nos ltimos graus, o que concorda com Boucher et al.(3), Doucete e Child(5), Herrington e Payton(9), que tambm no encontraram diferenas na atividade do msculo VMO nos em diferentes ngulos de flexo do joelho em indivduos normais. Apesar do aumento da atividade na CIVM a 90 dos msculos VMO e VLO no ser significativa em relao ao ngulo de 15, os resultados demonstraram que a diferena entre estes dois msculos e o msculo VLL aumenta na medida em que aumenta o ngulo de flexo do joelho. Alm disso, segundo Boucher et al. (3), na angulao de 90, as foras compressivas so maximizadas e a fora de cisalhamento so minimizadas facilitando no somente a atividade do msculo VMO mas aumentando o contato articular e favorecendo a nutrio articular. Para o fortalecimento seletivo do msculo VMO, o que se procura no somente o arco de movimento onde o mesmo apresente maior atividade, mas que tambm possa oferecer maior estabilidade, melhor distribuio de foras compressivas e tambm maior ativao em relao aos componentes laterais. Os exerccios de fortalecimento do msculo VMO nos ltimos graus de extenso at hoje tem sido preconizados para o tratamento destes pacientes. No entanto, fundamental que alm de mais ativo, o msculo VMO apresente uma vantagem de ativao em relao ao VLL e VLO. Nos ltimos graus de extenso do joelho h ainda menor contato articular, portanto maior instabilidade e Steikamp et al.(19), demonstraram que nos ltimos graus dos exerccios de extenso em cadeia cintica aberta, h tambm maior estresse femoropatelar j que o contato articular nesta angulao menor, portanto as foras compressivas apesar de menores so distribudas numa menor rea de contato, aumentando o estresse. Por outro lado, o ngulo de 90 de flexo do joelho, apresenta uma fora de reao femoropatelar maior, mas maior tambm o contato articular e a estabilidade femoropatelar. Sendo assim, os autores demonstraram que o estresse femoropatelar diminui medida que aumenta o ngulo de flexo do joelho.

in these muscles activity, nearly synchronic were found, suggesting a reciprocal activity at the patella control. According to Javadpour et al.(11) the traction balancing of the VMO and VLO is fundamental considering its muscular factor which determines patella position, as the opening kinetic chain exercise of the leg extension isolating the quadriceps contraction. The data from this study showed that VMO and VLO muscles have the same behaviour suggesting a synchronic role of stability and an antagonist stability of the patella in normal people. On the other hand the strength vector made by the VLO muscle, very associated with the iliotibial tract and lateralis retinaculum(1) may be able to alter the patella normal balancing, promoting an excessive tension in these structures could generate clinical pain and patella disorder. Considering the VMO muscle being more active during the last extension degrees it is well known(6,13,17), what subsided the use of these exercises in this traditional treatment. Equally, the concept of the strength of patellofemoral reaction increases according to knee flexion and decrease as long as reaching the final extension proposed by Hungerford & Barry(10), contributed to the exercises protocol to these patients that were based on exercises done at the last extension degrees. This work data showed the VMO muscle is not the most active at the last degrees., which is in accordance to Boucher et al.(3), Doucete & Child(5), Herrington & Payton(9), who did not find difference in VMO muscle activity at different angles of knee flexion in normal patients. Spite of the increase of the activity in CIVM at 90 VMO and VLO muscles not be significant in relation to 15 of knee flexion, the results showed the difference between these two muscles and the VLL muscle increasing as much as the knee flexion angle increases. Furthermore, according to Boucher et al.(3), at 90, the compressive strength is maximized and the shearing strength is minimized facilitating not only VMO muscle activity, but also increasing the articular contact facilitating articular nutrition. For the VMO selective muscle training, it is not only the Arch of movement what is searched where it shows more activity, but also offer higher stability, better compressive strength higher activation in relation to the lateralis components. The strength exercise of the VMO muscle at the last degrees extension until now has been proclaimed to these patients treatment. However, it is essential to this muscle, besides being more active, the VMO muscle show an advantage of activation if compared to VLL and VLO. At the last knee extension degrees there is even less articular contact, therefore higher and instability Stickup et al.(19), showed that at the last degrees of the extension exercises done in opening kinetic chain, there is also higher patellofemoral stress, as the particular contact angle is smaller, nevertheless the compressive strength, despite being smaller is distributed in a small contact area, increasing the stress. Otherwise, the 90 knee flexion, shows a higher strength of the stress, but the articular contact and the patellofemoral is higher as well., consequently the authors showed the patellofemoral decreases due to the increase of the knee flexion angle. Therefore, the isometric contraction exercise of the knee extension flexion at 90 can be proscribed to the rehabilitation program which is indicate VMO strength exercise.
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Portanto, os exerccios de contrao isomtrica de extenso de joelho a 90 de flexo podem ser indicados para o programa de reabilitao em que h indicao do fortalecimento do VMO.

CONCLUSION
The VLL and VLO muscles showed difference in the activity pattern, which could be considered physiologically distinct. Besides, the VLO muscle as the VMO also active, independent of the knee flexion angle, suggesting these muscles performance in reciprocal and synchronic patella stability. The isometric exercises of the knee extension at 90 higher activation of the VMO muscle was obsereved during in relation to lateral components, with important difference in relation to VLL muscle.

CONCLUSES
Os Msculos VLL e VLO apresentaram diferena no padro de atividade podendo ser considerados fisiologicamente distintos. Alm disso, o msculo VLO apresentou-se assim como o VMO igualmente ativo, independente do ngulo de flexo do joelho, sugerindo que estes msculos desempenham papel recproco e sincrnico na estabilizao patelar. Os exerccios isomtricos de extenso do joelho a 90 revelaram que ocorre maior ativao do msculo VMO em relao aos componentes laterais, com diferena significativa em relao ao msculo VLL.

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